BlueScript for Medicare Part D Option 1

Transcription

1 Prescription Drug Plan for Medicare Beneficiaries BlueScript for Medicare Part D Option 1 S Summary of Benefits January 1, December 31, 2006 State of Florida

2 Section 1 - Introduction to the Summary of Benefits for BlueScript for Medicare Part D Option 1 January 1, December 31, 2006 Thank you for your interest in BlueScript for Medicare Part D Option 1. Our plan is offered by Blue Cross and Blue Shield of Florida, Inc., a Medicare Prescription Drug Plan that contracts with Medicare. This Summary of Benefits tells you some features of our plan. It doesn t list every drug we cover, every limitation or exclusion. To get a complete list of our benefits, please call BlueScript for Medicare Part D Option 1 and ask for the Evidence of Coverage. YOU HAVE CHOICES IN YOUR MEDICARE PRESCRIPTION DRUG COVERAGE. As a Medicare beneficiary, you can choose from different Medicare prescription drug coverage options. One option is to get prescription drug coverage through a Medicare Prescription Drug Plan, like BlueScript for Medicare Part D Option 1. Another option is to get your prescription drug coverage through a Medicare Advantage Plan that offers prescription drug coverage. You make the choice. HOW CAN I COMPARE MY OPTIONS? The charts in this booklet list some important drug benefits. You can use this Summary of Benefits to compare the benefits offered by BlueScript for Medicare Part D Option 1 to the benefits offered by other Medicare Prescription Drug Plans or Medicare Advantage Plans with prescription drug coverage. WHERE IS BLUESCRIPT FOR MEDICARE PART D OPTION 1 AVAILABLE? The service area for this plan includes: Florida. You must live in Florida to join this plan. WHO IS ELIGIBLE TO JOIN? You can join this plan if you are entitled to Medicare Part A and/or enrolled in Medicare Part B and live in the service area. Eligible individuals may only enroll in one Medicare Prescription Drug Plan at a time and may not be enrolled in a Medicare Advantage Plan (HMO, PPO), unless they 2 are a member of Medicare Private-Fee-For-Services plan that does not offer Medicare prescription drug coverage or are enrolled in an 1876 Cost Plan. You may join a Medicare Prescription Drug Plan during certain times of the year. WHERE CAN I GET MY PRESCRIPTIONS? BlueScript for Medicare Part D Option 1 has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. BlueScript for Medicare Part D Option 1 may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. BlueScript for Medicare Part D Option 1 has a list of preferred pharmacies. At these pharmacies, you may get your drugs at a lower co-pay or coinsurance. A non-preferred pharmacy is still a network pharmacy, but you may have to pay more for your prescriptions. The pharmacies in our network can change at any time. You can ask for a Pharmacy Directory or call Customer Service for an upto-date list. DO YOU COVER MEDICARE PART B OR PART D DRUGS? We do not cover drugs that are covered under Medicare Part B as prescribed and dispensed. Generally, we only cover drugs, vaccines, biologicals and medical supplies that are covered under the Medicare Prescription Drug Benefit (Part D) and that are on our formulary. DOES MY PLAN HAVE A PRESCRIPTION DRUG FORMULARY? BlueScript for Medicare Part D Option 1 uses a formulary. A formulary is a preferred list of drugs selected to meet patient needs. The plan may periodically make changes to the formulary. If the formulary changes, affected enrollees will be notified, in writing before the change is made.

3 WHAT IS A MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM? A Medication Therapy Management (MTM) Program is a service that your plan may offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. If you have questions concerning our MTM Program please contact our Customer Service number listed at the end of this section. WHAT SHOULD I DO IF I HAVE OTHER INSURANCE IN ADDITION TO MEDICARE? If you have a Medigap (Medicare Supplement) policy that includes prescription drug coverage, you must contact your Medigap Issuer to let them know that you have joined a Medicare Prescription Drug Plan. If you decide to keep your current Medigap supplement policy, your Medigap Issuer will remove the prescription drug coverage portion of your policy and adjust your premium. Under certain circumstances, you can also buy a different Medigap policy without prescription drug coverage sold by your Medigap Issuer. Your Medigap Issuer cannot charge you more, based on any past or present health problems. Call your Medigap Issuer for details. If you or your spouse has, or is able to get, employer group coverage, you should talk to your employer to find out how your benefits will be affected if you join BlueScript for Medicare Part D Option 1. Get this information before you decide to enroll in this plan. HOW CAN I GET HELP WITH DRUG PLAN COSTS? Medicare beneficiaries with low or limited income and resources may qualify for additional assistance. If you qualify, your Medicare prescription drug plan costs, the amount of your premium and your drug costs at the pharmacy will be less. Once you have enrolled in BlueScript for Medicare Part D Option 1, Medicare will tell us how much assistance you are receiving, and we will send you information on the amount you will pay. If you are not receiving this additional assistance, you should contact Medicare to see if you might qualify. WHAT ARE MY PROTECTIONS IN THIS PLAN? All Medicare Prescription Drug Plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Prescription Drug Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare prescription drug coverage in your area. If BlueScript for Medicare Part D Option 1 ever denies coverage for your prescription drugs, we will explain our decision to you. You always have the right to appeal and ask us to review the claim that was denied. In addition, if your physician prescribes a drug that is not on our formulary, is not a preferred drug or is subject to additional utilization rules, you may ask us to make a coverage exception. Please call BlueScript for Medicare Part D Option 1 for more information about this plan Customer Service Hours: 8:00 a.m. - 9:00 p.m., Monday - Thursday, 9:00 a.m. - 9:00 p.m., Friday Current members should call (877) (TTY/TDD Florida Relay 711) Prospective members should call a local agent or call :00 a.m. - 8:00 p.m., Monday-Friday 8:00 a.m noon, Saturday. (TTY/TDD Florida Relay 711) For more information about Medicare, call Medicare ( ). TTY/TDD users should call You can call 24 hours a day, 7 days a week. Or visit If you have special needs, this document may be available in other formats. 3

4 If you have any questions about this plan s benefits or costs, please contact Blue Cross and Blue Shield of Florida, Inc. for details. Section 2 - Summary of Benefits Benefit Original Medicare BlueScript for Medicare Part D Option 1 4 Outpatient Prescription Drugs You pay 100% for most prescription drugs, unless you enroll in the Medicare Part D Prescription Drug program You pay $45.89 each month for your Medicare Part D prescription benefits. This plan does not cover Medicare Part B prescription drugs. This plan uses a formulary. A formulary is a preferred list of drugs selected to meet patient needs at a lower cost. If the formulary changes, you will be notified, in writing, before the change. To view the plan's formulary, go to on the web. People who have low incomes, who live in long term care facilities, or who have access to Indian/Tribal/Urban (Indian Health Service) facilities may have different out-of-pocket drug costs. Contact the plan for details. You pay a $100 yearly deductible. After you have paid your yearly deductible and before the total yearly drug costs (paid by both you and your plan) reach $2,250, you pay the following for prescription drugs: - $5 for a one-month (31 day) supply of Generic - Generic drugs you get at an in-network preferred pharmacy. - $30 for a one-month (31 day) supply of Preferred Brand - Preferred Brand drugs you get at an in-network preferred pharmacy. - 40% coinsurance for a one-month (31 day) supply of Non- Preferred Brand - Brand drugs you get at an in-network preferred pharmacy. - $15 for a three-month (90 day) supply of Generic - Generic drugs you get at an in-network preferred pharmacy. - $90 for a three-month (90 day) supply of Preferred Brand - Preferred Brand drugs you get at an in-network preferred pharmacy. - 40% coinsurance for a three-month (90 day) supply of Non- Preferred Brand - Brand drugs you get at an in-network preferred pharmacy. - $15 for a three-month (90 day) supply of mail order Generic - Generic drugs Continued on next page

5 S u m m a ry of Benefits Benefit Original Medicare BlueScript for Medicare Part D Option 1 - $90 for a three-month (90 day) supply of mail order Preferred Brand - Preferred Brand drugs - 40% coinsurance for a three-month (90 day) supply of mail order Non-Preferred Brand - Brand drugs After the total yearly drug costs (paid by both you and your plan) reach $2,250, you pay 100% of your prescription drug costs. After your yearly out-of-pocket drug costs reach $3,600, you pay: - $2 for generic drugs, or - $2 for preferred brand drugs, and - $5 for all other drugs, or - 5% coinsurance. Certain prescription drugs will have maximum quantity limits. Contact plan for details. Your provider must get prior authorization from BlueScript for Medicare Part D Option 1 for certain prescription drugs. Contact plan for details. Covered Part D drugs are available at out-of-network pharmacies in special circumstances including illness while traveling outside of the Plan's service area where there is no network pharmacy. In addition to paying the co-payments/co-insurances listed below, you will be required to pay the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescriptions. - $5 for a one-month (31 day) supply of Generic - Generic drugs you get at an out-of-network pharmacy. Continued on next page 5

6 S u m m a ry of Benefits Benefit Original Medicare BlueScript for Medicare Part D Option 1 - $30 for a one-month (31 day) supply of Preferred Brand - Preferred Brand drugs you get at an out-of-network pharmacy. - 40% coinsurance for a one-month (31 day) supply of Non- Preferred Brand - Brand drugs you get at an out-of-network pharmacy. - $15 for a three-month (90 day) supply of Generic - Generic drugs you get at an out-of-network pharmacy. - $90 for a three-month (90 day) supply of Preferred Brand - Preferred Brand drugs you get at an out-of-network pharmacy. - 40% coinsurance for a three-month (90 day) supply of Non- Preferred Brand - Brand drugs you get at an out-of-network pharmacy. 6

7 Your Notes 7

8 S CMS Approval Date: 09/2005

9 Prescription Drug Plan for Medicare Beneficiaries BlueScript for Medicare Part D Option 2 S Summary of Benefits January 1, December 31, 2006 State of Florida

10 Section 1 - Introduction to the Summary of Benefits for BlueScript for Medicare Part D Option 2 January 1, December 31, 2006 Thank you for your interest in BlueScript for Medicare Part D Option 2. Our plan is offered by Blue Cross and Blue Shield of Florida, Inc., a Medicare Prescription Drug Plan that contracts with Medicare. This Summary of Benefits tells you some features of our plan. It doesn t list every drug we cover, every limitation or exclusion. To get a complete list of our benefits, please call BlueScript for Medicare Part D Option 2 and ask for the Evidence of Coverage. YOU HAVE CHOICES IN YOUR MEDICARE PRESCRIPTION DRUG COVERAGE. As a Medicare beneficiary, you can choose from different Medicare prescription drug coverage options. One option is to get prescription drug coverage through a Medicare Prescription Drug Plan, like BlueScript for Medicare Part D Option 2. Another option is to get your prescription drug coverage through a Medicare Advantage Plan that offers prescription drug coverage. You make the choice. HOW CAN I COMPARE MY OPTIONS? The charts in this booklet list some important drug benefits. You can use this Summary of Benefits to compare the benefits offered by BlueScript for Medicare Part D Option 2 to the benefits offered by other Medicare Prescription Drug Plans or Medicare Advantage Plans with prescription drug coverage. WHERE IS BLUESCRIPT FOR MEDICARE PART D OPTION 2 AVAILABLE? The service area for this plan includes: Florida. You must live in Florida to join this plan. WHO IS ELIGIBLE TO JOIN? You can join this plan if you are entitled to Medicare Part A and/or enrolled in Medicare Part B and live in the service area. Eligible individuals may only enroll in one Medicare Prescription Drug Plan at a time and may not be enrolled in a Medicare Advantage Plan (HMO, PPO), unless they 2 are a member of Medicare Private-Fee-For-Services plan that does not offer Medicare prescription drug coverage or are enrolled in an 1876 Cost Plan. You may join a Medicare Prescription Drug Plan during certain times of the year. WHERE CAN I GET MY PRESCRIPTIONS? BlueScript for Medicare Part D Option 2 has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. BlueScript for Medicare Part D Option 2 may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. BlueScript for Medicare Part D Option 2 has a list of preferred pharmacies. At these pharmacies, you may get your drugs at a lower co-pay or coinsurance. A non-preferred pharmacy is still a network pharmacy, but you may have to pay more for your prescriptions. The pharmacies in our network can change at any time. You can ask for a Pharmacy Directory or call Customer Service for an upto-date list. DO YOU COVER MEDICARE PART B OR PART D DRUGS? We do not cover drugs that are covered under Medicare Part B as prescribed and dispensed. Generally, we only cover drugs, vaccines, biologicals and medical supplies that are covered under the Medicare Prescription Drug Benefit (Part D) and that are on our formulary. DOES MY PLAN HAVE A PRESCRIPTION DRUG FORMULARY? BlueScript for Medicare Part D Option 2 uses a formulary. A formulary is a preferred list of drugs selected to meet patient needs. The plan may periodically make changes to the formulary. If the formulary changes, affected enrollees will be notified, in writing before the change is made.

11 WHAT IS A MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM? A Medication Therapy Management (MTM) Program is a service that your plan may offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. If you have questions concerning our MTM Program please contact our Customer Service number listed at the end of this section. WHAT SHOULD I DO IF I HAVE OTHER INSURANCE IN ADDITION TO MEDICARE? If you have a Medigap (Medicare Supplement) policy that includes prescription drug coverage, you must contact your Medigap Issuer to let them know that you have joined a Medicare Prescription Drug Plan. If you decide to keep your current Medigap supplement policy, your Medigap Issuer will remove the prescription drug coverage portion of your policy and adjust your premium. Under certain circumstances, you can also buy a different Medigap policy without prescription drug coverage sold by your Medigap Issuer. Your Medigap Issuer cannot charge you more, based on any past or present health problems. Call your Medigap Issuer for details. If you or your spouse has, or is able to get, employer group coverage, you should talk to your employer to find out how your benefits will be affected if you join BlueScript for Medicare Part D Option 2. Get this information before you decide to enroll in this plan. HOW CAN I GET HELP WITH DRUG PLAN COSTS? Medicare beneficiaries with low or limited income and resources may qualify for additional assistance. If you qualify, your Medicare prescription drug plan costs, the amount of your premium and your drug costs at the pharmacy will be less. Once you have enrolled in BlueScript for Medicare Part D Option 2, Medicare will tell us how much assistance you are receiving, and we will send you information on the amount you will pay. If you are not receiving this additional assistance, you should contact MEDICARE to see if you might qualify. WHAT ARE MY PROTECTIONS IN THIS PLAN? All Medicare Prescription Drug Plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Prescription Drug Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare prescription drug coverage in your area. If BlueScript for Medicare Part D Option 2 ever denies coverage for your prescription drugs, we will explain our decision to you. You always have the right to appeal and ask us to review the claim that was denied. In addition, if your physician prescribes a drug that is not on our formulary, is not a preferred drug or is subject to additional utilization rules, you may ask us to make a coverage exception. Please call BlueScript for Medicare Part D Option 2 for more information about this plan Customer Service Hours: Monday, Tuesday, Wednesday, Thursday, 8:00 a.m. - 9:00 p.m. Eastern Friday, 9:00 a.m. - 9:00 p.m. Eastern Current members should call (877) (TTY/TDD Florida Relay 711) Prospective members should call (800) (TTY/TDD Florida Relay 711) For more information about Medicare, call MEDICARE ( ). TTY/TDD users should call You can call 24 hours a day, 7 days a week. Or, visit If you have special needs, this document may be available in other formats. 3

12 S u m m a ry of Benefits Benefit Original Medicare BlueScript for Medicare Part D Option 2 1. Outpatient Prescription Drugs You pay 100% for most prescription drugs, unless you enroll in the Medicare Part D Prescription Drug program You pay $57.71 each month for your Medicare Part D prescription benefit. This plan does not cover Medicare Part B prescription drugs. This plan uses a formulary. A formulary is a preferred list of drugs selected to meet patient needs at a lower cost. If the formulary changes, you will be notified, in writing, before the change. To view the plan's formulary, go to on the web. People who have low incomes, who live in long term care facilities, or who have access to Indian/Tribal/Urban (Indian Health Service) facilities may have different out-of-pocket drug costs. Contact the plan for details. You pay a $100 yearly deductible. After you have paid your yearly deductible and before the total yearly drug costs (paid by both you and your plan) reach $2,250, you pay the following for prescription drugs: - $5 for a one-month (31 day) supply of Generic - Generic drugs you get at an in-network preferred pharmacy. - $30 for a one-month (31 day) supply of Preferred Brand - Preferred Brand drugs you get at an in-network preferred pharmacy. - 40% coinsurance for a one-month (31 day) supply of Non Preferred Brand - Brand drugs you get at an in-network preferred pharmacy. - $15 for a three-month (90 day) supply of Generic - Generic drugs you get at an in-network preferred pharmacy. - $90 for a three-month (90 day) supply of Preferred Brand - Preferred Brand drugs you get at an in-network preferred pharmacy. - 40% coinsurance for a three-month (90 day) supply of Non Preferred Brand - Brand drugs you get at an in-network preferred pharmacy. - $15 for a three-month (90 day) supply of mail order Generic - Generic drugs 4

13 S u m m a ry of Benefits Benefit Original Medicare BlueScript for Medicare Part D Option 2 See Section 3, page 7, for more information. - $90 for a three-month (90 day) supply of mail order Preferred Brand - Preferred Brand drugs - 40% coinsurance for a three-month (90 day) supply of mail order Non Preferred Brand - Brand drugs. After the total yearly drug costs (paid by both you and your plan) reach $2,250, you pay 100% of your prescription drug costs. After your yearly out-of-pocket drug costs reach $3,600, you pay the greater of: - $2 for generic drugs. - $2 for a preferred brand drug - $5 for all other drugs, or - 5% coinsurance. Certain prescription drugs will have maximum quantity limits. Contact plan for details. Your provider must get prior authorization from BlueScript for Medicare Part D Option 2 for certain prescription drugs. Contact plan for details. Covered Part D drugs are available at out-of-network pharmacies in special circumstances including illness while traveling outside of the Plan's service area where there is no network pharmacy. In addition to paying the co-payments/co-insurances listed below, you will be required to pay the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescriptions. - $5 for a one-month (31 day) supply of Generic - Generic drugs you get at an out-of-network pharmacy. Continued on next page 5

14 S u m m a ry of Benefits Benefit Original Medicare BlueScript for Medicare Part D Option 2 - $30 for a one-month (31 day) supply of Preferred Brand - Preferred Brand drugs you get at an out-of-network pharmacy. - 40% coinsurance for a one-month (31 day) supply of Non Preferred Brand - Brand drugs you get at an out-of-network pharmacy. - $15 for a three-month (90 day) supply of Generic - Generic drugs you get at an out-of-network pharmacy. - $90 for a three-month (90 day) supply of Preferred Brand - Preferred Brand drugs you get at an out-of-network pharmacy. - 40% coinsurance for a three-month (90 day) supply of Non Preferred Brand - Brand drugs you get at an out-of-network pharmacy. See Section 3, page 7, for more information. 6

15 Section 3 - Summary of Benefits Additional information for our members: 1. A $100 deductible applies to preferred brand and non-preferred brand medications (see page 4). 2. Generics medications have first dollar coverage (see page 4 and page 6). 3. There is generic coverage only through the coverage gap. 7

16 S CMS approval date: mm/yyyy